Alcoholism



Medical Author: Joachim Gruber, MD, PhD. Coauthor(s): Brett Roth, MD; Dennis C Daley, PhD
Medical Editors: Michael D Burg, MD; Francisco Talavera, PharmD, PhD; Anthony Anker, MD, FAAEM

Synonyms and Keywords
alcohol dependence, alcohol addiction, alcohol abuse, drinking problem, CAGE questionnaire, alcoholic ketoacidosis, detoxification, alcoholism, alcohol intoxication,inebriated, drunk, drunk driving, DWI, driving while intoxicated, DUI, driving under influence, BAC, blood alcohol concentration, intoxicated, Breathalyzer, Breathalyzer test, delirium tremens, DTs, stabilization,
detoxification, rehabilitation, alcoholic, alcoholism
Alcoholism Overview

Alcohol problems vary in severity from mild to life threatening and
affect the individual, the person's family, and society in numerous
adverse ways. Despite all of the focus on drugs such as cocaine,
alcohol remains the number one drug problem in the United States.
According to community surveys, over 13% of adults in the United States
will experience alcohol abuse or dependence (also referred to as
alcoholism) at some point in their lives.
Withdrawal, for those physically dependent on alcohol, is much more dangerous than withdrawal from heroin or other narcotic drugs.

• Alcohol abuse refers to excessive or problematic use with one or more of the following:
  
  
  
  • Failure to fulfill major obligations at work, school, or home
    
  • Recurrent use in situations where it is hazardous (such as driving a car or operating machinery)
    
  • Legal problems
    
  • Continued use of alcohol despite having social, family, or interpersonal problems caused by or worsened by drinking
    
  
  

• Alcohol dependence refers to a more serious disorder and involves
  excessive or maladaptive use leading to 3 or more of the following:
  
  
  
  • Tolerance changes (need for more to achieve desired effect, or achieving the effect with lesser amounts of alcohol)
    
  • Withdrawal symptoms following a reduction or cessation of drinking (such as sweating, rapid pulse, tremors, insomnia, nausea, vomiting, hallucinations, agitation, anxiety, or seizures) or using alcohol to avoid withdrawal symptoms (for example, early morning drinking)
    
  • Drinking more alcohol or drinking over a longer period of time than intended (loss of control)
    
  • Inability to cut down or stop
    
  • Spending a great deal of time drinking or recovering from its effects
    
  • Giving up important social, occupational, or recreational activities
    
  • Continuing to drink despite knowing alcohol use has caused or worsened problems
    
  • Alcoholism Causes
    
  • 
    
    
  • 
    The cause of alcoholism is not well established. There is growing evidence for genetic
    and biologic predispositions for this disease, but this research is
    controversial. Studies examining adopted children have shown that
    children of alcoholic biological parents have an increased risk of
    becoming alcoholics. Relatively recent research has implicated a gene
    (D2 dopamine
    receptor gene) that, when inherited in a specific form, might increase a
    person's chance of developing alcoholism. Twice as many men are
    alcoholics. And 10-23% of alcohol-consuming individuals are considered
    alcoholics. Usually, a variety of factors contribute to the
    development of a problem with alcohol. Social factors such as the
    influence of family, peers, and society, and the availability of
    alcohol, and psychological factors such as elevated levels of stress,
    inadequate coping mechanisms, and reinforcement of alcohol use from
    other drinkers can contribute to alcoholism. Also, the factors
    contributing to initial alcohol use may vary from those maintaining it,
    once the disease develops.
    
  • Alcoholism Symptoms
    
    Alcoholism is a disease. It is often diagnosed more through behaviors
    and adverse effects on functioning than by specific medical symptoms.
    Only 2 of the diagnostic criteria are physiological (those are tolerance
    changes and withdrawal symptoms).
    
  • Alcohol abuse and alcoholism are associated with a broad range of medical, psychiatric,
    social, legal, occupational, economic, and family problems. For
    example, parental alcoholism underlies many family problems such as
    divorce, spouse abuse, child abuse and neglect, welfare dependence, and criminal behaviors, according to government sources.
    
    
    
    • The great majority of alcoholics go unrecognized by physicians and
      health care professionals. This is largely because of the alcoholic's
      ability to conceal the amount and frequency of drinking, denial of
      problems caused by or made worse by drinking, the gradual onset of the disease, and the body's ability to adapt to increasing alcohol amounts.
      
    • Family members often deny or minimize alcohol problems and
      unwittingly contribute to the continuation of alcoholism by well-meaning
      behaviors such as shielding the alcoholic from adverse consequences of
      drinking or taking over family or economic responsibilities. Often the
      drinking behavior is concealed from loved ones and health care
      providers.
      
    • Alcoholics, when confronted, will often deny excess consumption
      of alcohol. Alcoholism is a diverse disease and is often influenced by
      the alcoholic's personality as well as by other factors. Therefore,
      signs and symptoms often vary from person to person. There are, however,
      certain behaviors and signs that indicate someone may have a problem with alcohol. These behaviors and signs include insomnia, frequent falls, bruises of
      different ages, blackouts, chronic depression,
      anxiety, irritability, tardiness or absence at work or school, loss of
      employment, divorce or separation, financial difficulties, frequent
      intoxicated appearance or behavior, weight loss, or frequent automobile collisions.
      
    • Late signs and symptoms include medical conditions such as pancreatitis, gastritis, cirrhosis, neuropathy, anemia, cerebellar
      atrophy, alcoholic cardiomyopathy (heart disease),
      Wernicke's encephalopathy (abnormal brain functioning), Korsakoff's dementia, central pontine myelinolysis (brain degeneration), seizures, confusion, malnutrition, hallucinations, peptic ulcers, and gastrointestinal bleeding.
      
    
    
  • Compared with children in families without alcoholism, children
    of alcoholics are at increased risk for alcohol abuse, drug abuse,
    conduct problems, anxiety disorders, and mood disorders. Alcoholic
    individuals have a higher risk of psychiatric disorders and suicide.
    They often experience guilt, shame, and depression, especially when
    their alcohol use leads to significant losses (for example, job,
    relationships, status, economic security, or physical health). Many
    medical problems are caused by or made worse by alcoholism as well as by
    the alcoholic's poor adherence to medical treatment.
    
    
  • When to Seek Medical Care
    
    People who drink alcohol to the point that it interferes with their
    social life, professional life, or health should contact a doctor to
    discuss the problem. The great difficulty lies in the fact that denial
    plays a large part in alcoholism. Consequently, alcoholics rarely seek
    professional help voluntarily.
    Often a family member or employer convinces or forces the
    alcoholic to seek medical treatment. Even if an alcoholic accepts
    treatment because of pressure from family, an employer, or a medical
    professional, he or she can benefit from it. Treatment may help this
    person develop motivation to change the alcohol problem.
    Several alcohol-related conditions require immediate evaluation in a hospital's Emergency Department.
    Alcohol is involved in greater than 50% of motor
    vehicle deaths, 67% of drownings, 70-80% of fire-related deaths, and
    67% of murders. It is imperative that emergency care be sought
    immediately when alcohol has contributed to an injury. This is very
    important because someone who is intoxicated may not be able to reliably assess
    the severity of the injury they have sustained or inflicted. An intoxicated
    person may, for example, not notice that they have a fractured neck vertebra
    (broken neck) until it is too late (that is, paralysis has occurred).
    
  • Alcohol withdrawal requires emergency treatment. When withdrawing
    from alcohol, a person classically goes through 4 phases: tremulousness
    (the shakes), seizures, hallucinations, and delirium tremens (DTs). These stages are described in further detail:
    
    
    
    • During the tremulous stage, the person will exhibit a tremor of his or her hands and legs. This can be seen if the person extends his or her hand and tries to hold it still. This symptom is often accompanied by anxiety and restlessness.
      
    • Seizures often follow the tremulous stage. They are commonly
      generalized seizures during which the entire body shakes uncontrollably
      and the person loses consciousness. Seizures occur in up to 25% of
      people withdrawing from alcohol. If you see someone having a seizure, attempt to lay the person on one side so they don't inhale any vomit or secretions into their lungs.
      If possible, protect the person's head or other body parts from
      knocking uncontrollably onto the floor or against other potentially
      harmful objects. Do not place anything inside the person's mouth while they are having a seizure.
      
    • Hallucinations affect about 25% of people undergoing major
      alcohol withdrawal. Visual hallucinations are the most common type of hallucination
      experienced during alcohol withdrawal. People will classically "see"
      insects or worms crawling on walls or over their skin. Often this is
      associated with tactile (feeling) hallucinations in which alcoholics think they feel insects crawling on their skin. This phenomenon is called formication.
      Auditory (hearing) hallucinations can also occur during withdrawal,
      although less commonly than the other types of hallucinations.
      
    • The most dangerous stage of alcohol withdrawal is called delirium
      tremens (DTs). About 5% of people withdrawing from alcohol experience
      DTs. This condition occurs about 48-72 hours after drinking stops. The
      hallmark of this stage is profound delirium (confusion). People are
      awake, but thoroughly confused. This is accompanied by agitation,
      delusions, sweating, hallucinations, rapid heart rate, and high blood pressure.
      This is a true emergency. Studies have shown that death will occur in
      about 35% of these people if they are not treated promptly. Even with
      appropriate medical treatment, this condition is associated with a high
      death rate.
      
    
    
  • Alcoholic ketoacidosis (AKA)
    is another condition for which emergency medical treatment should be
    sought. AKA often starts within 2-4 days after an alcoholic has stopped
    consuming alcohol, fluids, and food, often because of gastritis or
    pancreatitis. Not uncommonly, AKA and alcohol withdrawal syndromes are
    seen at the same time. AKA is characterized by nausea, vomiting, abdominal pain, dehydration, and an acetone-like odor on the person's breath. This occurs when the alcoholic has become depleted of carbohydrate fuel stores and water. Therefore, the body begins to metabolize fat and protein into ketone bodies for energy. Ketone
    bodies are acids that accumulate in the blood changing its acidity and
    causing the person to feel even sicker, thus perpetuating a vicious
    cycle.
    
  • Alcoholism is often associated with other psychiatric disorders such as anxiety, depression, and psychosis.
    This psychiatric illness, often combined with a reduced level of sound
    judgment while intoxicated, leads to suicides, suicide attempts, and suicidal
    gestures by alcoholics. Obviously, a person who has attempted suicide,
    or is believed to be in serious or imminent danger of committing
    suicide, should be taken quickly to the Emergency Department
    
  • Exams and Tests
    
    The diagnosis
    of alcoholism is generally made by reviewing the person's behavior
    except when the person has symptoms of withdrawal or damage to organs as
    a result of alcohol consumption.
    Alcoholism, as defined, is the consumption of alcohol to the
    point at which it interferes with the individual's life from an
    occupational, social, or health standpoint. It follows that behavior
    exhibited by an alcoholic can be interpreted in different ways by
    different people. This often makes the diagnosis of alcoholism somewhat
    difficult.
    
  • Several screening tests are routinely employed by many health care
    professionals to identify people at risk for alcoholism. Such tests
    usually consist of 1 or more questionnaires. Commonly used tests are the
    Michigan Alcoholism Screening Test (MAST), the TACE questionnaire, and the CAGE questionnaire.
    
    
    
    • The CAGE questionnaire, for example, asks the following 4 questions.
      "Yes" answers to 2 or more of these questions indicate a high
      likelihood of alcoholism.
      
      
      
      • Have you felt you should Cut down on your drinking?
        
      • Have people Annoyed you by criticizing your drinking?
        
      • Have you felt bad or Guilty about your drinking?
        
      • Have you ever had to drink first thing in the morning to steady your nerves or get rid of a hangover (Eye-opener)?
        
      
      
    • The TACE questionnaire is very similar. It also asks 4
      questions. The more "yes" answers a person has to these questions, the
      higher the likelihood of this person drinking excessively.
      
      
      
      • How many drinks does it Take to get you high?
        
      • Have people Annoyed you by criticizing your drinking?
        
      • Have you ever felt you ought to Cut down on your drinking?
        
      • Have you ever had a drink first thing in the morning to steady your nerves (Eye opener)?
        
      
      
    
    
  • The doctor may draw blood to evaluate it for liver functions, anemia, and electrolyte
    levels (blood chemistry levels). Alcoholics often have elevated liver
    function tests, which indicate liver damage. Gamma glutamyl transferase
    is the most sensitive liver function test. It can be elevated after only
    a few weeks of excess alcohol consumption. Alcoholics may also have
    anemia (low blood count), as well as electrolyte disturbances including low potassium, low magnesium, and low calcium.
    
  • Often the initial visit with a doctor is for medical
    or surgical complications of alcohol consumption. In those cases the doctor
    will perform and order additional tests depending on the symptoms (for
    example, abdominal pain, heart failure, alcohol withdrawal, or cirrhosis).
    
  • Alcoholism Treatment
    
    Self-Care at Home
    
  
  
  
  
  
  
  
  
  • Alcoholism is best treated by professionals trained in addiction
    medicine. Physicians and other health care workers are best suited to
    manage alcohol withdrawal and the medical disorders associated with
    alcoholism.
    In fact, home therapy without supervision by a trained professional may be life threatening because of complications from alcohol withdrawal syndrome. Usually an alcoholic will experience alcohol withdrawal 6-8 hours after cutting down or stopping alcohol consumption.
    Several levels of care are available to treat alcoholism. Medically managed hospital-based detoxification and rehabilitation
    programs are used for more severe cases of dependence that occur with
    medical and psychiatric complications. Medically monitored
    detoxification and rehabilitation programs are used for people who are
    dependent on alcohol and who do not require more closely supervised
    medical care. The purpose of detoxification is to safely withdraw the
    alcoholic from alcohol and to help him or her enter a treatment program.
    The purpose of a rehabilitation program is to help the alcoholic accept
    the disease, begin to develop skills for sober living, and get enrolled
    in ongoing treatment and self-help programs. Most detoxification
    programs last just a few days. Most medically managed or monitored
    rehabilitation programs last less than 2 weeks.
    Many alcoholics benefit from longer-term rehabilitation programs, day treatment programs, or outpatient
    programs. These programs involve education, therapy, addressing
    problems contributing to or resulting from the alcoholism, and learning
    skills to manage the alcoholism over time.
    These skills include, but are not limited to, the following:
    
  • Learning to identify and manage cravings to drink alcohol
    
  
  
• Resisting social pressures to engage in substance use
  

• Changing health care habits and lifestyle (for example, improving diet and sleep hygiene, and avoiding high-risk people, places, and events)
  

• Learning to challenge alcoholic thinking (thoughts such as, I need a drink to fit in, have fun, or deal with stress)
  

• Developing a recovery support system and learning how to reach out
  for help and support from others (for example, from members of self-help
  programs)
  

• Learning to deal with emotions (anger, anxiety, boredom, depression) and stressors without reliance on alcohol
  

• Identifying and managing relapse warning signs before alcohol is used
  

• Anticipating the possibility of relapse and addressing high-risk relapse factors
  
• Medical Treatment
  
• 
  
• A team of professionals is often needed to treat the alcoholic. The
  physician usually plays a key role in medical stabilization and
  facilitating treatment entry, but others are routinely needed beyond the
  initial management (for example, alcoholism counselors, social workers,
  family therapists, psychologists, and pastoral counselors).
  Treatment of the alcoholic can be divided into 3 stages.
  Initially, the person has to be medically stabilized. Next, he or she
  must undergo a detoxification process, followed by long-term abstinence and rehabilitation.
  
• Stabilization: It is the treating doctor's responsibility to treat
  any medical conditions related or unrelated to alcoholism. Vast arrays
  of medical and surgical complications are associated with alcoholism,
  but only stabilization of alcohol withdrawal and alcoholic ketoacidosis
  are discussed here.
  
  
  
  • Alcohol withdrawal is treated by oral or IV hydration along with
    medications that reverse the symptoms of alcohol withdrawal. The most
    common medications used to treat alcohol withdrawal symptoms are benzodiazepines. Commonly used medications in this class are lorazepam (Ativan), diazepam (Valium), and chlordiazepoxide (Librium). They can be given by IV, orally, or by injection. Diazepam also comes as a rectal
    suppository. Chlordiazepoxide generally takes longer to have an effect
    than diazepam or lorazepam. Therefore, it is less commonly used in
    withdrawal emergencies. Pentobarbital
    is another medication occasionally used to treat alcohol withdrawal. It
    has an effect similar to benzodiazepines but is more likely to slow
    down breathing,
    making it less attractive for this use. Occasionally the agitated and
    confused person may have to be physically restrained until he or she
    becomes more calm and coherent.
    
  • Alcoholic ketoacidosis is treated with IV fluids and carbohydrates.
    This is usually done in the form of sugar-containing fluid given by IV
    until the person can resume drinking fluids and eating.
    
  • Any alcoholic treated by a doctor should receive thiamine
    (vitamin
    B1). Thiamine levels are often low in alcoholics, and deficiency of
    this important vitamin could lead to Wernicke's encephalopathy, a
    disorder characterized initially by the eyes looking in different
    directions from each other. If thiamine is given in a timely fashion,
    this potentially devastating disorder can be completely reversed. In the
    emergency setting, thiamine is customarily given as an injection. Folate (a vitamin) and magnesium are often given to alcoholics as well.
    
  
  
• Detoxification: This stage involves stopping alcohol
  consumption. This is very difficult for an alcoholic and requires
  extreme discipline. It is often performed in an inpatient
  setting. Alcohol is not available in this setting. The person is
  treated with the same medications discussed in the treatment of alcohol
  withdrawal, namely, benzodiazepines. During detoxification the
  medication is measured carefully to prevent withdrawal and is then
  gradually tapered off until no withdrawal symptoms are evident. This
  usually requires a few days to a week. Recently, physician-assisted,
  outpatient detoxification has become popular. In the current managed
  health care setting, it is increasingly difficult to obtain coverage for
  in-hospital detoxification.
  
• Rehabilitation: Short- and long-term residential programs aim
  to help people who are more severely dependent on alcohol develop skills
  not to drink, to build a recovery support system, and to work on ways
  to keep them from drinking again (relapsing).
  
  
  
  • Short-term programs last less than 4 weeks. Longer programs last for
    a month to a year or more. These are structured programs that provide
    therapy, education, skills training, and help develop a long-term plan
    to prevent relapsing.
    
  • Outpatient counseling (individually, in groups, or with
    families) can be used as a primary treatment or as a "step-down" for
    people as they come out of a residential or structured day program.
    
  • Outpatient counseling can provide education on alcoholism and
    recovery, can help the person learn skills not to drink, and spot early
    signs of potential relapse.
    
  • There are several very effective individual treatments
    delivered by professional counselors in outpatient treatment clinics.
    These treatments are Twelve-Step Facilitation Therapy, Motivational
    Enhancement Therapy, and Cognitive-Behavioral Coping Skills. A
    well-known self-help program is Alcoholics Anonymous
    (AA). Other self-help programs (for example, Women for Sobriety,
    Rational Recovery, and SMART Recovery) allow alcoholics to stop drinking
    and remain sober on their own.
    
  • People who deny or minimize their alcohol problem or who don't
    care about taking action benefit from brief interventions such as
    Motivational Enhancement Therapy or Motivational Interviewing.
    
  
  
• Several medications are available to assist the person in abstaining from alcohol consumption.
  
  
  
  • The classic medication is disulfiram (Antabuse). It interferes with alcohol metabolism
    resulting in a metabolite that makes the person very uncomfortable and
    nauseated when consuming alcohol. The greatest problem with disulfiram
    is that people will often stop taking the medication to drink alcohol.
    To overcome this problem, disulfiram is available as an implantable
    device that is inserted under the skin. Fatalities have been reported
    when people taking disulfiram have ingested large amounts of alcohol.
    Furthermore, disulfiram has been associated with several types of
    neurologic conditions, including optic neuritis, which can lead to visual disturbances and eye pain.
    
  • Other medications used in preventing relapse are naltrexone (ReVia), acamprosate (Campral), and a class of antidepressants called selective serotonin reuptake
    inhibitors (SSRIs). Some researchers suggest that naltrexone and
    acamprosate seem to be the most effective medications studied, although
    SSRIs are not as effective. Disulfiram seems to have a positive effect
    on maintaining an alcohol-free lifestyle, yet the magnitude of this
    effect seems to be rather limited. Therefore, naltrexone is being
    increasingly used. Studies suggest alcoholics who drink while on
    naltrexone drink less alcohol and have less severe relapses compared
    with those not on it. Acamprosate has recently been approved by the Food and Drug Administration in the United States. When compared to placebo
    (sugar pills), it was effective in helping people abstain from alcohol.
    It is generally recommended that these medications be used in
    conjunction with alcoholism counseling.
    
    Follow-up
    
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  • 
    
  • 
    The alcoholic must first make the decision that he or she must stop
    using alcohol. Without such a resolve, achieving long-term sobriety is
    unlikely.
    
  • To avoid an impulsive relapse, the person's home should be alcohol-free.
    
  
  
• The person should enroll in a social support group or counseling
  program. Also, social situations that encourage alcohol consumption
  should be avoided.
  

• If medication is prescribed to help maintain sobriety, the person
  must take the medication according to a strict schedule. Meeting with a
  counselor is mandatory. When the urge to relapse becomes strong, the
  person should immediately contact a member of his or her support group
  and discuss the urge.
  

Prevention


Prevention of alcoholism is best accomplished by abstinence. You must
first have access to alcohol before becoming an alcoholic. A strong family history
of alcoholism is a warning that you are at increased risk of becoming
an alcoholic. Increased awareness of such a risk may help modify your
attitude toward alcohol consumption. A strong social support system and
early medical or psychiatric intervention may also help prevent the escalating consumption of alcohol so characteristic of alcoholism.Outlook


Several studies have shown that about half of alcoholics who have
successfully undergone detoxification will relapse within 6-12 months.
Remaining alcohol-free is a very difficult task for most alcoholics.

• Alcoholism is a chronic disease not unlike diabetes or congestive heart failure.
  If alcoholism is considered a chronic disease, a treatment success rate
  of 50% does not differ much from the success rates in other chronic
  illnesses.
  

• If a person continues to drink excessively after numerous or ongoing treatments, theirprognosis is very poor. Persistent heavy drinkers will often succumb to the effects of alcohol.
  
• Authors and Editors
  
  Author:Joachim Gruber, MD, PhD, Staff Physician, Department of Emergency
  Medicine, Parkland Hospital, University of Texas Southwestern.
  
  Coauthor(s): Brett Roth, MD, Assistant Professor,
  Department of Emergency Medicine, Division of Clinical Toxicology, University of
  Texas Southwestern; Dennis C Daley, PhD, Director of Center for Psychiatric and
  Chemical Dependency Services, Western Psychiatric Institute and Clinic,
  Associate Professor, Department of Psychiatry, University of Pittsburgh School of Medicine.
  
  Editors:Michael D Burg, MD, Assistant Clinical
  Professor, Department of Emergency Medicine, University Medical Center,
  University of California at San Francisco-Fresno; Francisco Talavera,
  PharmD,
  PhD, Senior Pharmacy Editor, eMedicine; Anthony Anker, MD, FAAEM,
  Attending Physician, Emergency Department, Mary Washington Hospital,
  Fredericksburg, VA.